This study used Medicare data to compare emergency department (ED) use by rural and urban elderly beneficiaries. The Health Care Financing Administration’s National Claims File was used to identify services provided to Medicare beneficiaries in Washington State in 1994. Patients were classified by urban, adjacent rural, or remote rural residence. We identified ED visits and associated diagnostic codes, assigned severity levels for presenting conditions, and determined the specialties of physicians providing ED services. This study found that the rural elderly living in remote areas were 13% less likely to visit the ED than their urban counterparts. Causes of ED use by the elderly did not vary meaningfully by location. Most ED visits by this group were for conditions that seem appropriate for this setting. Given the similarity of diagnostic conditions associated with ED visits, local EDs must be capable of dealing with the same range of emergency conditions as urban EDs. Funded by HRSA’s ORHP.